Download MBBS Surgery Presentations 38 Medical Errors Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 38 Medical Errors PPT-Powerpoint Presentations and lecture notes


Medical and Surgical Errors

Dept. of Surgery

"Many doctors know the guilt, shame and self

doubt that occur when patients suffer a serious

complication or die due to a mistake made by

the clinician, healthcare team or health care

system"


? A 79 year old Male was on regular dialysis due

to CRF. Once while undergoing dialysis he

started having SOB. He was admitted to the

ICU and was managed. Next day he

complained of epigastric pain for which he

was prescribed antacid, which he received

from his nurse. Only........ It was'nt an antacid,

it was pancuronium!
Objectives

(1)To become familiar with common patient

safety definitions.

(2) To become familiar with the causes of

medical errors.

(3) To become familiar with the common types

of medical errors.

(4) To become familiar with recommendation

that help prevent adverse events/medical errors

in the healthcare system.

Patient Safety Definitions

? Medical error, defined as the failure of a

planned action to be completed as intended

or the use of a wrong plan to achieve an aim.

? Adverse event, defined as an injury caused by

medical management rather than by the

underlying disease or condition of the patient.

? Preventable adverse event, defined as an

injury that could have been avoided as a result

of an error or system design flaw.
? Ameliorable adverse event, defined as an injury whose

severity could have been substantial y reduced if

different actions or procedures had been performed or

followed.

? Negligence, defined as whether the care provided

failed to meet the standard of care reasonably

expected of an average physician qualified to take care

of the patient in question.

? Error of omission, occurs when a necessary procedure

or intervention failed to be performed leading to

morbidity or mortality to the patient involved.

Why do errors happen?

? Al humans make errors: indeed, "the ability to

make mistakes" al ows human beings to function

? Most of medicine is complex and uncertain
? Most errors result from "the system"--inadequate

training, long hours, ampoules that look the same,

lack of checks, etc

? Healthcare has not tried to make itself safe


EPIDEMIOLOGY

Epidemiology

? Medical errors are the

3rd leading cause of

death in the US.

? In India, 5.2 million

medical errors occur

annually.
TYPES OF MEDICAL ERRORS

? Misdiagnosis/delayed

diagnosis/overdiagnosis
? Unnecessary

tests/procedures

? Unnecessary treatment
? Medication errors

? "Never-events"
? Uncoordinated care

? HAIs
? "Not- so- accidental

accidents"

? Pressure ulcers
? Missed warning signs

? "Jholachaap" doctors
Failure to provide

prophylactic treatment

? Failure of

communication


RISK FACTORS

Risk factors

? Age

? Complexity of care

? Emergency or acute care

? Insufficient knowledge

? Ignorance of sources of error

? Low community spirit

? Clinician autonomy and low acceptance to

change
CAUSES

? "July effect"
? Poor communication

? Improper

documentation
? Illegible handwriting

? Inadequate nurse to

patient ratio
? Cost cutting measures

? Similarly

named/sounding

medicines
? Disconnected reporting

systems in the hospital

? Sleep deprivation
? Extreme specialization

? Logistic problems
? Equipment related

issues

? Unstructured discharge

summaries


MEDICATION ERRORS

Medication errors

? There are inherent risks associated with

therapeutic use of drugs.

? The hazards that result from such risk are

called drug-misadventuring, which includes

both ADRs and medication error.

? Episodes in drug misadventuring that should

be preventable through effective systems

control.
TYPES OF MEDICATION ERROR

? Prescribing error
? Omission error

? Wrong time error
? Unauthorized drug error

? Improper dose error
? Wrong dosage form

error

? Wrong administration

technique error
? Deteriorated drug error

? Monitoring error
? Compliance error

CAUSES OF MEDICATION ERROR


Causes of medication error

? Look alike/sound alike

? Illegible handwriting

? Inaccurate dose calculation

? Inadequately trained personnel

? Inappropriate use of abbreviations

? Labelling errors

? Excessive workload

? Medication unavailable

SURGICAL ERROR
? It is a preventable

mistake during surgery.

Surgical errors go

beyond the known risk

of surgery.

TYPES OF SURGICAL ERROR
? Nerve injury

? Wrong site
? Wrong patient

? Wrong procedure
? Wrong equipment

? Surgical souvenirs!


? Anaesthesia errors
CAUSES OF SURGICAL ERROR

Insufficient

Incompetence

preop planning

Improper

Fatigue

surgical

techniques

Poor

communication
The Second Victim

? Is the physician that

cared for the patient.

? Implications for the

second victim: -

? Emotional and

psychological

? May result in a career

change

? May destroy the

reputation and career

How to think of error?

? An individual failing
? Blaming them for carelessness, forgetfullness
? Wil not solve the problem--Doctors wil

hide errors

? It is often the best people who make the

worst mistakes

? Mishaps tend to occur in recurrent patterns


How to think of error?

? A systems failure

? This is the starting point for redesigning the

system and reducing error.

? Team work
? Better communication
? Evidence based practice

PREVENTION
INTERNATIONAL PATIENT SAFETY

GOALS(IPSG)
MISCONCEPTIONS

? "Bad apples" are a common cause- faulty

process of care delivery is more common.

? High risk procedures are responsible for most

avoidable errors- surgical errors are harder to

conceal, but errors occur at all levels.



Bottom line

? Fallibility is part of the human condition

? We can't change the human condition but

we can change the conditions under which

people work.

? Naming, blaming and shaming have no

remedial value

? We need to design health care systems that

put safety first (First, do no harm)
? These goals highlight problematic areas in health

care

? Describe evidence-based and expert-based

consensus solutions

? It is essential that EVERYONE should be familiar

and able to incorporate into daily practice
IPSG 1-Identify Patients Correctly

Two-fold Intent :
? FIRST, to identify the individual as the person

for whom the service or treatment is intended.

? SECOND, to match the service or treatment to

that individual.

IPSG 1-Identify Patients Correctly

? Patients must be identified using "two unique

identifiers" i.e. FULL NAME and CRN

? MUST NEVER use patient's room or location

to identify patient.

? ALWAYS ask the patient / guardian / parent to

verbalize patient's name whenever possible


IPSG 2- IMPROVE EFFECTIVE

COMMUNICATION

Verbal medication orders are reserved for code/emergency

situations ONLY.

? When receiving a medication telephone order from a

physician:

? Nurse A writes the order in the physician order sheet.

? Nurse B will read back the order written by Nurse A to the

physician.

? The prescriber will verify the order is correct to Nurse B.

? Both Nurse A and Nurse B must document the date and

time the order was received, badge number of the

prescriber, and their own names, job title and badge

numbers and both must sign the order sheet.

IPSG 2- IMPROVE EFFECTIVE

COMMUNICATION

? Reporting critical results of diagnostic tests.

? The technologist/reporter wil provide the report to the Receiver

(Requesting Physician/Ward Nurse).

? The receiver wil document (hand -WRITE) the critical results.

? The receiver (or another person - could be another nurse) wil READ

BACK the information provided, including the patient's medical

record number and name to the reporter.

? The technologists/reporter wil verify the information is correct.

? Both the reporter and the receiver must document the READ BACK

verification procedure was carried out; date and time the report

was received, badge number of the person providing/receiving the

report.


IPSG 2- IMPROVE EFFECTIVE

COMMUNICATION

? Handovers of patient care:
? During shift changes
? Between different levels of care
? From in-patient units to diagnostic units




IPSG 3-Improve the Safety of High-

Alert Medications

? Medications that pose an increased risk of

causing significant harm to patients if used in

error.

? Independent double checks in handling is one

of the safety measures.

? Look alike & Sound alike


IPSG 4- Ensure Correct-Site, Correct-

Procedure, Correct-Patient Surgery

? UNIVERSAL PROTOCOL:
1.Marking the surgical site
2.Pre-operative verification
3. Time out

Marking the surgical site

? made by the person performing the procedure

with a permanent skin marker.

? takes place with the patient AWAKE and AWARE,

if possible.

? to be done in al cases involving laterality (right,

left), multiple structures (fingers, toes, lesions) or

multiple levels or region (spine).

? be done using an instantly recognizable mark

(ARROW) that is consistent throughout the

hospital.


TIME OUT ? Pause with a purpose

? full verification that is performed immediately prior to the

induction of Anaesthesia or the start of an invasive

procedure

? the entire care team actively and verbally confirms:

? Patient's identity (two identifiers)

? Procedure to be performed

? Correct procedure side/site

? Necessary imaging, equipment, implants or special

requirements are present

IPSG 5- Reduce the Risk of HAI

? 5 moments of hand hygiene
? Before patient contact
? Before aseptic task
? After body fluid exposure
? After patient contact
? After contact with patient surroundings


? Wash hands with soap and water when hands

are visibly soiled.

? Use alcohol-based hand rub when hands are

not visibly soiled

IPSG 6- Reduce the Risk of Patient

Harm Resulting from Falls

? Upon initial admission assessment, Physicians

should screen Patient's Functional status

which include "FALL RISK".

? Functional Screening should be documented in

the Physicians History and Physical form

complimented by nurses' assessment.

? Communicate to nurses for implementation.






SUMMARY
Bottom line

? Fallibility is part of the human condition

? We can't change the human condition but

we can change the conditions under which

people work.

? Naming, blaming and shaming have no

remedial value

? We need to design health care systems that

put safety first (First, do no harm)

MISCONCEPTIONS

? "Bad apples" are a common cause- faulty

process of care delivery is more common.

? High risk procedures are responsible for most

avoidable errors- surgical errors are harder to

conceal, but errors occur at all levels.



This post was last modified on 08 April 2022